Sleep as a Mood Stabilizer in Bipolar Disorder
Synopsis: If you have bipolar disorder, getting the right amount of sleep at the right time of day is absolutely critical in achieving and maintaining mood stability. Good sleep at night clearly exerts mood-stabilizing benefits. This article addresses several strategies for improving mood stability in bipolar disorder and discusses the tradeoffs faced in regulating your activities and schedule.
BY LEN LANTZ, MD / 9.26.23; No. 68 / 9 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.
Getting bipolar disorder better is not just about doing one thing
While I promise to share some insights regarding sleep in bipolar disorder, I think it’s appropriate to start with some background information to set realistic expectations. If I said, “You can fix bipolar disorder simply by fixing your sleep,” I wouldn’t be telling the truth about most people who experience the condition. A more accurate statement is, “Ensuring good sleep can help tremendously in dealing with bipolar disorder.” But that means ensuring good sleep among many other effective strategies.
First, you need to determine whether or not you even have bipolar disorder. Maybe you have something else that can seem like bipolar disorder, such as a substance abuse problem, major depressive disorder combined with severe posttraumatic stress disorder (PTSD), severe attention deficit hyperactivity disorder (ADHD), premenstrual dysphoric disorder (PMDD), or borderline personality disorder. To start, you can complete online rating scales such as the Mood Disorder Questionnaire (MDQ) and the Sydney Bipolar Screener (SBS), but you’ll also need a psychiatrist or other mental health provider skilled in diagnostic assessments to get clear answers.
The most helpful approaches that most people with bipolar disorder find involve self-regulation. If you have bipolar disorder, you’re probably tired of the wild (and depressing) ride that your mood has been taking you on for years. To have a better, more stable mood, you are open to placing a few self-imposed limits on yourself and developing healthy habits that you have chosen for yourself, such as ensuring 7-9 hours of sleep at night, eating healthy meals every day, and avoiding situations that throw you out of balance.
How can you regulate your mood if you are unable or unwilling to regulate your activities? When it comes to bipolar disorder, acknowledging and accepting the tradeoff of self-imposed limits is, to a very large degree, what will determine if your mood is stable most of the time or chronically unstable.
What’s the tradeoff involved in bipolar disorder?
The tradeoff to achieve stability in bipolar disorder is a paradigm shift for many people who have never sought or received good care for their mood disorder. It involves a reassessment and, potentially, a new definition of what you believe a “normal” mood should be. What is your definition of a normal mood? Many people with bipolar disorder define their “normal” mood as manic or hypomanic. The problem with this is that a manic or hypomanic mood state is not normal and cannot be sustained by the brain. Nine times out of ten, the next mood state following mania is depression (Goodwin, et al. J Clin Psychiatry. 2004). The same is likely true for hypomania. When you expect your “normal” mood to be elevated, you will suffer for it. You will constantly be chasing after the mood elevation, which is not normal and not a place of stability, only to fall back into depression.
The tradeoff in achieving mood stability also involves developing and sustaining several healthy habits that promote mood stability. I’ll discuss these habits, including good sleep, below.
People who are open to the tradeoff to achieve mood stability often also develop a greater sense of peace over having bipolar disorder. They recognize that only certain aspects of the disorder are under their control, so they take action in areas where they know they can make a positive impact. If you are at a place in life where you can say, “It’s not my fault that I have bipolar disorder, but it’s my responsibility to myself to do something effective about it,” then you are off to a great start.
Stability is about no longer pushing yourself out of balance
What kind of mood control do you want when dealing with bipolar disorder? If you want stability, there is a tradeoff. If you want a life of spontaneity that is carefree, unplanned, and without some form of self-discipline, then you are likely going to struggle with your mood control. Why? You cannot control mood episodes with quick fixes. I realize that people try, often by using drugs or alcohol, but the temporary change in mood caused by alcohol and other substances does not really work in the long run and typically leaves people feeling worse than when they started.
Please keep in mind that mood stability is actually enjoyable. The goal in achieving mood stability is not to flatline your mood and remove all emotions. In fact, that is a potential side effect, not the desired effect, of some mood-stabilizing medications. The goal in seeking mood stability is that the highs are not quite so high and the lows aren’t too low. Extreme mood states are expected to be briefer and come around less often. Having fewer extreme mood episodes also helps to reduce feelings of regret, because the fallout from these episodes might include behaviors that were out of character for you but resulted in problems in your relationships, career, and finances.
Disrupted sleep is a huge contributor to instability in bipolar disorder
I’ve noticed a pattern among people with bipolar disorder, which is to dysregulate when feeling depressed. If they throw themselves out of balance when depressed by using substances or going without sleep, they know they will see a temporary lift in their mood. Why? Many people with bipolar disorder have figured out that they can see brief improvement in their mood with sleep deprivation.
Even people who do not have bipolar disorder can see a lift in their mood for one day following sleep deprivation. The problem for people with bipolar disorder is that the lift following sleep deprivation can lead to mania/hypomania or significant mood cycling. In bipolar disorder, sleep disturbance is the most common symptom that occurs before mania and the sixth most common symptom preceding depression (Jackson, et al. Journal of Affective Disorders. 2003). If that’s true, then why do people with bipolar disorder allow themselves or cause themselves to become sleep-deprived? Well, I think the answer is simple. Most of the people I know would choose mood instability over feeling consistently depressed.
So, then, is excessive sleep a good thing? It turns out that the answer is no. People with bipolar disorder who have excessive sleep are more likely to experience a depressive episode (Kaplan, et al. Journal of Affective Disorders. 2011).
When it comes to bipolar disorder, the right amount of consistent sleep is needed.
What I’ve personally seen regarding sleep and bipolar disorder
There is something interesting about sleep that I’ve seen in my clinical practice. When people with bipolar disorder regularly work the night shift, it is nearly impossible for them to get to a place of mood stability. With every person I work with who has bipolar disorder, I encourage them not to work an overnight shift. Why? There is just something about natural light and the brain that cannot be substituted or replaced. The circadian rhythm is a thing that affects everyone, and it hits people with bipolar disorder especially hard.
Sometimes the circadian rhythm is referred to as a circadian pacemaker, which gets reset when you are awake during daylight hours. Your body is designed to have your sleep-wake cycle, which is driven by this circadian pacemaker, aligned or synchronized with the day-night cycle. Simply getting solid sleep within a random 24-hour period is not enough. The time of day when you sleep is incredibly important. If you are not sleeping at night, there is a good chance that you have thrown your circadian pacemaker out of whack. And when this happens, mood instability is just around the corner.
One benefit of some mood-stabilizing medications is that they are sedating. So, if they make you tired and help you sleep at night, that’s a great thing. I’ve also seen some astonishing things in clinical practice. I’ve seen a dramatic improvement in mood stability, sometimes with a medication that has no mood-stabilizing properties, when all the medicine helped the person do was sleep. Lastly, I’ve witnessed dramatic improvements in mood stability after stopping meds that were causing insomnia.
While sleep is critical, its importance is not just in getting a solid 7-9 hours of sleep in 24 hours. It’s about getting good sleep at night. Even researchers have found this to be true, using scheduled periods of sleep at night to prevent – and potentially treat – mania and rapid mood cycling in people with bipolar disorder (Wehr, et al. Biological Psychiatry. 1998).
A story about improving mood stability by improving sleep
Sean was a 25-year-old guy who was known for his wild side. Never backing down from a dare had resulted in so many injuries that he was on a first-name basis with his orthopedic surgeon. Sean valued having a ton of energy, intense experiences, and, at times, feelings of invincibility. In his teens and early twenties, he dampened his mood swings and insomnia with weed and alcohol, but he never sought help for his mood. He had always counted on his depressive episodes lasting less than a week until last year – when his depression lasted for months. That had never happened before, and it was awful. His whole world ground to a halt. He stopped going to work and communicating with his friends. He nearly lost everything.
Thankfully, Sean eventually got help. When he went to his primary care doctor for his depression, he was also screened for bipolar disorder. The bipolar screening test was positive, so he was referred to a psychiatrist who confirmed that he had bipolar disorder. The last year was tough for him. He had to try 2 different meds before he got free from his depression, then his mood started cycling again in the spring. Even with several mood stabilizers, his mood kept cycling until his psychiatrist pinned him down on his sleep. “I know, I know,” Sean said. “You’ve been nagging me about my sleep for a year.”
Sean had already made several healthy changes in his life, but his irregular sleep was his final holdout. He loved staying up late and he felt free when he chose to stay up all night gaming. His psychiatrist asked, “Is it worth it? I know you like staying up late, but is it worth staying up late only to see your mood skyrocket for a few days and then plummet back into depression?” Sean and his doctor talked at length about what he would be giving up or trading away for good sleep and greater mood stability. Sean identified gaming as his preferred activity at night. It’s when he socialized. He didn’t want to lose that, so he decided that he could try to connect with friends who gamed in the evening instead of late at night.
“Why not give it a try for a few months?” his doctor reasoned. “Let’s see what it’s like when you are sleeping solidly every night.” It turned out that it was pretty good. Sean’s mood actually stabilized quickly. And his doctor was able to taper him off one of his mood stabilizers. In the end, he was able to do plenty of gaming, and an unexpected perk was that his daytime energy was so much better. He hadn’t realized how exhausted he had been during the day until his energy improved. Now his only problem was to figure out what else he wanted to do with his newfound energy.
Other healthy habits that promote mood stability
In addition to regulating sleep, there are other healthy habits I want to mention briefly. There are many strategies that people with bipolar disorder find work for them, so there is no single recipe or list of strategies that will necessarily work for you. Here are some of the strategies that I have seen dramatically help some of my patients:
Avoid drugs
Alcohol
Nicotine
Cannabis
Eliminate (or use with caution) medications that destabilize mood
Medications that cause insomnia
Medications with antidepressant effects
Stimulant ADHD medications if not taken in conjunction with a mood stabilizer
Consistently take a mood stabilizer
One or more mood stabilizers can dramatically help with mood stability, provided the side effects do not outweigh the benefits
Avoid missing doses of helpful medications
Develop healthy habits and routines
Eat healthy meals
Exercise
Add routine and regularity to your daily schedule
Deepen healthy relationships with people who encourage stability and regulation
It's possible to improve mood by improving sleep
Getting good sleep alone is unlikely to fix bipolar disorder, but it can help tremendously. Most people find that the tradeoffs for achieving improved mood stability are tiny compared to the enormous benefit of having a better and more predictable mood. You can do this! Some people choose to stop working an overnight shift or find a different job that has morning or afternoon shifts. Others start setting a scheduled bedtime and wake time. Doctors and therapists are eager to support you in regulating your sleep and will encourage you as you work to bring more balance into your life. If you have to make sacrifices to get good sleep at night or make other changes to promote mood stability, make sure that you also think about what you will be gaining for yourself and the people you love.
For further reading, check out:
Len’s Article, “Behavioral Activation for Depression”
Len’s Article, “Change Depressive Habits when the Wind Is at Your Back”
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